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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003429
Report Date: 10/08/2021
Date Signed: 10/08/2021 11:10:16 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2021 and conducted by Evaluator Anthony Tuck
COMPLAINT CONTROL NUMBER: 27-AS-20210830092807
FACILITY NAME:SKY PARK GARDENSFACILITY NUMBER:
347003429
ADMINISTRATOR:SHERRY RICHARDSONFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 77DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan McClureTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility location for an unannounced visit on 10/08/2021 and was met by Assistant Administrator Susan McClure. LPA explained the reason for the visit to conclude the findings of the complaint allegation listed above.

LPA conducted interviews with 8 out of 77 residents and the Assistant Administrator on 09/08/2021. LPA conducted 4 staff interviews via telephone on 10/04/2021. LPA reviewed copies of invoices for current pest control service company and last two months prior. LPA inspected 10 resident rooms and buildings and grounds for pests. LPA learned that the facility has pest control services come out to service the facility bi-weekly. There is not substantial evidence to support or disprove that the alleged violation occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements; LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegation may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20210830092807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SKY PARK GARDENS
FACILITY NUMBER: 347003429
VISIT DATE: 10/08/2021
NARRATIVE
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Exit interview held with Assistant Administrator Susan McClure, a copy of this report was left with the facility upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2021 and conducted by Evaluator Anthony Tuck
COMPLAINT CONTROL NUMBER: 27-AS-20210830092807

FACILITY NAME:SKY PARK GARDENSFACILITY NUMBER:
347003429
ADMINISTRATOR:SHERRY RICHARDSONFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 77DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susan McClureTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility has overflowing garbage
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility location for an unannounced visit on 10/08/2021 and was met by Assistant Administrator Susan McClure. LPA explained the reason for the visit to conclude the findings of the complaint allegation listed above.

LPA conducted an interview with Assistant Administrator on 09/08/2021, LPA toured the facility buildings and grounds. LPA obtained photographs of dumpster area and observed a collection of old furniture and equipment outside by dumpsters. LPA received photographs from Administrator on 09/20/2021 indicating the dumpster area has been cleared. LPA observed the dumpster area as being cleared of old furniture and equipment upon arrival on 10/08/2021. LPA inspected area thoroughly with the Assistant Administrator and found the complete area to be free and clear of old equipment and overflowing garbage. Although the dumpster area was found to be cleared during today's visit, the allegation of the facility having overflowing garbage was observed during the initial inspection.

Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210830092807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SKY PARK GARDENS
FACILITY NUMBER: 347003429
VISIT DATE: 10/08/2021
NARRATIVE
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The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Assistant Administrator Susan McClure, a copy of the LIC 9099A, 9099C, 9099D and appeal rights were provided to the Assistant Administrator upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210830092807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKY PARK GARDENS
FACILITY NUMBER: 347003429
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2021
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by:
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 Administrator agrees to submit a written plan of procedures on how the facility will properly dispose of old equipment, furniture and garbage at the facility. Administrator will provide the POC to LPA via email by due date of 10/15/2021
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Based upon interviews and observations. The licensee failed to maintain a clean and safe environment free of clutter and garbage located in the dumpster disposal area of the facility. This poses as a potential health risk for persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5